Masi runs a public health system in which 64 percent of patients do not have insurance and cannot pay for their medical treatment. To pick up the tab, like many public health systems across the state, Masi has been relying on a federal Medicaid waiver intended to reimburse hospital systems like his for uncompensated care. The waiver was set to expire this year, but last week the Texas Health and Human Service Commission announced that the feds had offered a 15-month extension, expiring at the end of 2017. The HHSC called it a “big win” for Texas, and Masi, too, said the news was certainly a delight.
But only for now. He's already thinking about what happens when those 15 months end — that is, if state lawmakers do not negotiate a longer-term solution for Medicaid in Texas before then.
Texas is one of 19 states that has rejected the Affordable Care Act's Medicaid expansion, which would provide coverage to over one million uninsured Texans and allow the state to pull in an additional $6 billion in Medicaid funding annually. For now, by choosing to forgo the expansion, the state is leaving billions of dollars on the table — which, as Masi pointed out, all Texans are paying for anyway in federal taxes, but can't benefit from. Instead of accepting the expansion, Texas has been relying on this so-called Medicaid 1115 waiver. But as the feds have warned: After that 15-month extension is up, if Texas continues to refuse to accept Obama's Medicaid expansion, the feds will simply wean the state off of the waiver funding each year until there is none left.
“The only alternative we have after that,” Masi said, “is to move into the realm of cutting services.”
Here in Harris County, if Texas were to accept the Medicaid expansion, Masi said roughly 60,000 patients could be insured overnight, resulting in $85 million in revenue overnight for the Harris Health System. Without it, however, and without the uncompensated care funding, Masi said it will likely result in an undetermined combination of layoffs, fewer resources, and worse access to care. Deciding to leave more people uninsured, Masi said, means those people may likely only seek care once they are so ill that they end up in the emergency room.
"If your routine healthcare needs aren't met over time," Masi said, "chances are, what is a minor illness becomes an acute illness. You will ultimately end up in an emergency room someplace, without insurance, and that hospital will have to take care of you."
Which may also, indirectly, lead to higher insurance premiums for those who have commercial insurance, Masi said. Given it affects everyone in one way or another, Masi said that every CEO he knows in the Texas Medical Center is supporting the expansion. Should Texas continue to reject it once these 15 months are up, Masi said he isn't ready to start thinking about what that will mean for patients and staff. When asked what would be the first resources to be cut, he said:
“I'm not prepared to say. Everything we do is important. The most difficult decision any healthcare executive in the public arena will make is, if there has to be cuts, who will not get one? We haven't come to grips with that yet, because there's not a thing that we do where we say, 'It's kind of fluff.' Everything we do in our system, we do because patients are very much in need of the care. Anything we would be forced to cut would be vital services, and fewer people will be cared for.”
The head-scratcher, then, is why won't Texas just say yes to the feds and accept the Medicaid expansion?
In Texas, Governor Greg Abbott has repeatedly said that Medicaid expansion is “wrong for Texas,” saying that it's unconstitutional for the federal government to force it upon the state. But as for why it's wrong for more than a million Texans who would benefit, healthcare advocates said that the reasoning hasn't been as clear—and not just in Texas.
“This has really become a fight within the Republican Party,” said Joan Alker, a public policy professor and executive director of Georgetown University's Center For Children And Families. “I do think it's fair to say that, really, most of the opposition so far has been ideological opposition, and the intense dislike of Obamacare, the Affordable Care Act.”
Alker's colleague, Anne Dunkelberg, executive director of the Center for Public Policy Priorities, said that, nationally, the opposition to Medicaid expansion appears to be a knee-jerk reaction, one that hinges on an argument that is not supported by numbers, she said. “There's a rhetorical response that suggests that Medicaid is somehow particularly problematic in terms of healthcare cost,” Dunkelberg said. “It's really a talking point that's not supported by data. Medicaid is only about 16 percent of healthcare spending in the United States."
Masi said that, whenever he has tried to explain his predicament to the Republican leadership, the discussion has rarely ever gone beyond “We are not prepared to discuss this.” Given that Texas now has been afforded 15 months to make a decision, Masi is hoping that that will change and that lawmakers will look past the politics and instead at their constituents, the thousands of people the Harris Health System helps on a daily basis. Because even though the equation Masi is using to figure out how much fuel he has left in his budget is all about financial figures on paper, he said, what it really trickles down to is people, a sentiment that he is trying to make sure the lawmakers understand.
“It's a human equation,” he said. “Not to be melodramatic here, but [choosing not to expand Medicaid] reflects human suffering. If we're not able to provide care, it equates to human suffering.”